PATIENT CONSENT TO BEGIN ORTHODONTIC TREATMENT

By [Orthodontic Office]

Like any form of health care, orthodontic treatment has inherent risks and limitations. The potential
complications are seldom sufficient to offset the advantages of treatment but they should be considered
when deciding whether or not to proceed with orthodontic treatment. Great orthodontic results are
generally achieved by patients who understand their treatment goals and know what to do to fully
participate in their orthodontic treatment.

PATIENT’S RESPONSIBILITY: It is the patient’s responsibility to follow brushing and oral hygiene instructions
that are given, so no harm will come to tissues and teeth; to adhere to food restrictions to keep from
damaging teeth and orthodontic appliances; to timely come to all appointments; to wear elastics, retainers,
and headgear, if they are necessary, so treatment time will be as short as possible and to achieve best
results; and to visit the general dentist at least every six months for cleaning and examination. Additional
orthodontic charges may be incurred for replacement of appliances due to patient neglect, or excessive
extension of treatment caused by failure of patient cooperation. Patient cooperation is critical.

DECALCIFICATION (PERMANENT MARKINGS), DECAY, OR GUM DISEASE: These problems may occur if the
patient does not cooperate with proper brushing and flossing. Further, sugars and between meal snacks
should be reduced as much as possible. Maintaining proper dietary control is essential, especially by
minimizing the intake of sugar. Smoking or chewing tobacco has been shown to increase the risk of gum
disease and interfere with healing.

ROOT RESORPTION: In some cases, the ends of some of the teeth are shortened during treatment. In the
event of subsequent gum disease, this shortening could reduce the longevity of affected teeth. Under healthy
circumstances, the shortened teeth suffer no disadvantage. It should be noted that not all root resorption
arises from orthodontic treatment. Trauma, cuts, impaction, endocrine disorders, idiopathic reasons can also
cause root resorption. Severe resorption can increase the possibility of premature tooth loss.

PRE-EXISTING, NON-VITAL, DEVITALIZATION, TRAUMATIZED TEETH: Sometimes a tooth may have been
traumatized by a blow or have large fillings that cause damage to the nerve. It is possible for the nerve inside
a tooth to die during treatment thus requiring a root canal on the affected tooth. Severe cases may result in
tooth loss.

TMJ (TEMPORO-MANDIBULAR JOINT) PAIN: Orthodontic treatment may help remove dental causes of TMJ,
but not non-dental causes. Some patients may develop jaw joint noises, discomfort and facial pain related to
the jaw during or after treatment. The current belief is that these problems are caused more by habitual
grinding of the teeth rather than the way in which the teeth bite. If such a problem arises, treatment by
another specialist may be required.

DISCOMFORT: As the mouth is sensitive, you may expect some discomfort due to adjustment and application
of appliances. Nonprescription pain medication may be used to address this adjustment pain.

ORAL SURGERY/EXTRACTIONS: To achieve optimal results, oral surgery or tooth extraction may be necessary
together with orthodontic treatment, especially to correct jaw imbalances. Third molars (wisdom teeth) may
develop and change alignment. Your dentist and orthodontist may recommend that your third molars be
removed.

IMPACTED, UNERUPTED, ANKYLOSED TEETH: Teeth may become impacted (trapped below gums or bone),
fail to erupt, or ankylosed (fused to bone). Treatment of these conditions depends on individual
circumstances and may require extraction, surgical transplantation/exposure, or prosthetic replacements.

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OCCLUSAL ADJUSTMENT: You can expect minimal imperfections in the way your teeth meet following the
end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to
fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth,
thereby “flattening” surfaces in order to reduce the possibility of a relapse.

ALLERGIES: Allergies to medicine and orthodontic materials may occur during treatment. This may be
avoided if disclosed to us. If they are unknown to us, it is impossible to predict reactions.

TREATMENT TIME: The total time for treatment can be delayed beyond our estimate. Abnormal facial
growth, poor elastic wear, or headgear cooperation, broken appliances and missed appointments are all
important factors that could lengthen treatment time and affect the quality of the result.

INJURY FROM APPLIANCES AND HEADGEAR: Some orthodontic appliances can be injurious. Headgear, if
improperly handled, may cause injury to the face or eyes. Orthodontic appliances may be accidentally
swallowed or aspirated, or may irritate or damage oral tissue. Contact sports and similar activities should not
be performed while headgear and other extra-oral appliances are worn.

RETURN OF THE ORIGINAL PROBLEM: We intend to obtain the best result possible. Some orthodontic
problems, however, tend to return to their original condition to a small degree. Careful cooperation during
the retention phase of treatment will keep this relapse to a minimum.

ADDITIONAL TREATMENT: Unforeseen circumstances (such as abnormal growth or gum disease) may cause
us to recommend a form of additional treatment not previously discussed. If this occurs, we will carefully
explain the reasons for a change in the treatment plan and any extra fees before proceeding.

TERMINATION OF TREATMENT: It is understood that treatment can be terminated for failure to cooperate,
missing appointments, not wearing appliances, excessive breakage, failure to keep financial commitments,
relocation, personal conflicts or for any other reason the orthodontist feels necessary. If termination is
necessary, the patient will be given ample time to locate another orthodontist to continue treatment or the
braces will be removed.

CONSENT TO USE RECORDS: I hereby give my permission for the use of orthodontic records, including
photographs for purposes of professional consultations, research, education or publication in professional
journals.

I have read the above and have had an opportunity to discuss this information with [Orthodontic Office]. All
questions have been answered to my satisfaction. I authorize [Orthodontic Office] and its team to perform
the necessary orthodontic treatment.

**In a case where the patient is a minor, I authorize [Orthodontic Office] and its team to perform the
necessary treatment in my absence.

________________ __________________________________________
Date Patient/**Parent/**Legal Guardian

_________________ __________________________________________
Date Witness

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